Regeneration of the anterior cruciate ligament: current strategies in tissue engineering

Which led me to search for this researchers more current work; here’s a publication:

Regeneration of the anterior cruciate ligament: Current strategies in tissue engineering

World Journal of Orthopedics

2015

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4303781

“The worldwide estimation of young sports players that require surgery following a knee injury lies between 17%-61%. The anterior cruciate ligament (ACL), a main stabilizing structure of the knee, is one of the most commonly injured ligaments. In the USA alone, around 350,000 reconstructive surgeries of the ACL are performed annually. According to the National Center for Health Statistics, the annual costs for the acute care of these injuries are around $6 billion”

“relatively high failure rates of ACL reconstruction, especially in young and active patients, have been reported for allografts. An incidence of osteoarthritis as high as 50% within 7-14 years after injury and reconstruction of the ACL is still the main drawback of this surgical strategy. The development of osteoarthritis following ACL injury is not fully understood and may be caused not only by the limitation of the current grafts, but also by the initial joint trauma and the trauma caused by the surgeon.”

and the most recent thing I came across from last year next post…

Anterior Cruciate Ligament Repair Revisited. Preliminary Results of Primary Repair with Internal Brace Ligament Augmentation: A Case Series

The next report I came across really put the it into perspective the need for alternatives given complications and lower than toted outcomes of ACL reconstruction, and how InternalBrace initially measured up within the first 3 months – back in 2015.

Anterior Cruciate Ligament Repair Revisited. Preliminary Results of Primary Repair with Internal Brace Ligament Augmentation: A Case Series

https://www.omicsonline.org/open-access/anterior-cruciate-ligament-repair-revisited-preliminary-results-of-primary-repair-with-internal-brace-ligament-augmentation-a-case-series-2161-0533-1000188.php?aid=52900

“estimates suggest that in the United States alone 400,000 ACL reconstructions are carried out each year. As the majority of ACL injuries occur in patients of working age, the economic burden to both patients and society is considerable”

“ACL reconstruction. The technique either involves removing or bypassing residual ACL tissue, without any attempt to repair the ligament”

“In the majority of cases, sufficient tissue remains for a repair to be considered, particularly if surgery is carried out within 6 weeks of injury”

*What really strikes me – perhaps from my continuous improvement background – is removal & reconstruction is a work around to the problem*

“A number of problems have been identified with ACL removal however, with autograft harvest associated with a degree of morbidity from tissue loss. Hamstring muscle weakness following harvesting averages 10% in most studies with anterior knee pain common with patellar tendon grafts”

“loss of proprioception a particular problem. Not surprisingly therefore the majority of studies of gait after ACL reconstruction show abnormal gait patterns and altered knee kinematics which may be linked to the higher rate of early Osteoarthritis”

Orthopedic & Muscular System: Current Research ISSN:2161-0533

“68 consecutive patients who underwent Anterior Cruciate Ligament repair with IBLA were followed for a minimum of 1 year following #surgery … between Sept 2011 and Sept 2014”

“Only patients who had completed one year of follow-up were included … max time from injury to surgery was increased to 3 months”

*I’m within this time frame, & receiving a diagnosis that will not facilitate a successful outcome*

“Beyond this time the ACL remnant begins to remodel and retract, and the tissue is no longer able to be placed back at its original attachment point”

“Loss of proprioception is important as it may lead to overloading of the ACL graft ... It is estimated that less than 50% of patients return to sport after reconstruction, and those that do often find that they cannot perform at the same level as pre-injury/pre-surgery”

“The majority of studies assessing gait and knee kinematics post-ACL reconstruction show an improvement in gait pattern compared to pre-surgery, but compensatory mechanisms of muscle use persist in the majority of patients indicating sub-optimal performance of the reconstructed graft. Graft donor site morbidity from tissue loss and scarring is well documented with hamstring weakness and anterior knee pain problematic after hamstring and patellar tendon harvesting respectively”

“modifications introduced to the ACL reconstruction technique to try to improve outcomes include: changes in graft tunnel position, double bundle rather than single bundle grafts, retention of the ACL remnant and variations in graft fixation techniques.

NONE of these modifications have been shown to make a significant difference to patient reported outcomes.”

*Earlier return to function could result in less hospitalisation and healthcare usage post-operatively, with an earlier return to work and sport. This could potentially have benefits not only to the patient but to the health service and society as a whole.

the time to surgery in patients undergoing acute ACL repair with IBLA is likely to be shorter than those undergoing ACL removals, the majority of whom will have failed a period of conservative care.

https://www.omicsonline.org/open-access/anterior-cruciate-ligament-repair-revisited-preliminary-results-of-primary-repair-with-internal-brace-ligament-augmentation-a-case-series-2161-0533-1000188.php?aid=52900

A Review of Ligament Augmentation with the InternalBrace

Despite the timeline passing for DIS eligibility, the fact a repair option regrowing ACL’s has existed for so long spurred me to keep looking.

I came across article A Review of Ligament Augmentation with the InternalBrace

https://www.researchgate.net/publication/288006378_A_review_of_ligament_augmentation_with_the_InternalBrace_The_surgical_principle_is_described_for_the_lateral_ankle_ligament_and_ACL_repair_in_particular_and_a_comprehensive_review_of_other_surgical_ap

Halfway through the 18 pages I find some application to the ACL, how it reduces harvest site morbidity & cost.

Based on the US stat 1 – 10 per 1000 people = 100k – 400k ACL reconstruction s occur annually; Canada would have 32,000+ reconstructions, which involves removing or bypassing the remaining ACL, despite in the majority of cases sufficient tissue remains for a repair to be considered, particularly within 3 months.

It explained grafts do not produce a normal feeling knee; there’s a loss of proprioception, which when present is important as this prevents overloading of the ACL graft; and estimates less than 50% of patients return to sport, and those that do often find they cannot perform at the same level.

“Graft harvest is associated with a degree of morbidity from tissue loss; muscle weakness with hamstring grafts & anterior knee pain are common with patellar tendon grafts.”

“there is a decrease in knee power and work performed postoperatively by the muscles around the injured knee”

“compensatory mechanisms of muscle use persist in the majority of patients, indicating sub optimal performance of the reconstructed graft”

There was also a study cited confirming “significant increase in osteoarthritic changes as early as a year post op” and stats on reconstruction failures.

“The clinical benefits of a well prepared and healed ACL are likely to be greater for patients than those offered by a traditional ACL reconstruction”

“Sufficient ACL tissue can remain for up to 3 months following ACL injury to allow a repair; procedure is time dependent as the ACL remnants are not suitable for direct repair after the tissue retracts and atrophies”

• Perhaps this is an option I am still within the timeline for.  I have just under 5 weeks left if it is.

The Internal Brace is a 2mm high molecular weight polyethylene that protects a repair by being a check rein if the ligament is stretched beyond its physiological range.  Should failure occur reconstruction remains possible without compromise to the knee joint.

Earliest patients are from Sept. 2011

If found suitable, the ability to repair a torn ACL can be confirmed at the time of #surgery.

“Early phase rehabilitation was consistently accelerated.  Limited pain and selling facilitated early range of movement, muscle control and restoration of function.”

“…avoidance of donor site morbidity & minimal surgical trauma.”

“better outcomes were achieved for ACL repair at the majority of time points”

“Pain…was less in patients”

“4 cases had arthroscopically confirmed ACL healing”

“…eliminate the shortcoming of current reconstruction techniques”

“…change in orthopaedic practice relegating ligament reconstruction appropriately as a salvage procedure; only if the tissues fail to heal adequately after augmentation & repair.”

The article is from back in 2015, so I start searching the authors of the published medical journal studies and references to find other research they’ve done.

info on ALL (Anterolateral Ligament)

May 13, 2018

53 days since injury.

I come across some info on ALL (Anterolateral Ligament) and find:

‘Despite technologic advances in the surgical technique for ACL reconstruction, some patients continue to have rotational instability post operatively, decreasing the return to sport rate. Failures can occur because of improper tunnel positioning, problems with patient rehabilitation, or non-optimal incorporation of the graft used for reconstruction’

and

‘recent biomechanical studies have shown it is an important stabilizer against anterolateral tibial rotation’

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5263705           

Then found in Dr DiFelice NY’s article

Ground Breaking ACL Repair Approach Could Help 80,000 in US Alone

“Skier Veronika Velez Zuzulova competed 20 weeks after suffering a torn right ACL: an injury that according to traditional thinking should have required ACL Reconstruction Surgery and an 8 - 12 month #recovery.

Foregoing the traditional, Zuzulova opted for ground breaking ACL repair surgery instead of ACL removal & graft reconstruction – that had her training just 6 weeks after surgery with enough time to enable her to be ready for the Pyeong Chang Olympic Games.”

“more than 150 Repairs and has published both two-year and five-year post-surgery data on his initial cohort to validate the procedure’s success”

“published more than 15 professional, peer-reviewed articles on the subject”

“unwarranted bias which limited ACL Repair as an option” 

“failing to recognize that ACL Repair success was much higher when treating specific types of tears, the data lead to the erroneous conclusion that ACL Repair was not a reliable course of action.”

Can “repair greater than 50% of the athletes who present to him with ACL tear”

“up to 80,000 of the 300,000 patients suffering ACL tears in the US alone may be helped”

French surgeon Dr. Bertrand Sonnery Cottet performed Zuzulova’s surgery, and again the article mentioned Scotland's Dr. Gordon MacKay at The Mackay Clinic.

Despite the mounting cases and supporting publications suggesting that, for the appropriate tear type, ACL Repair is the preferred treatment method, the shift away from unnecessary reconstructions —widely ascribed to by orthopaedic surgeons—has been slow. 

"To keep all options open, athletes, parents and healthcare professionals need to take a closer look at ACL Repair," says Dr. Gregory S. DiFelice. This is especially important for younger athletes who have been shown to have high rates of re-injury and can develop significant arthritic changes as early as 10 years post-reconstruction. 

"success rate with ACL Repair is approximately 95% in all comers from recreational up to professional athletes. In the few patients that have suffered re-injury, Reconstruction was performed without undue difficulties. It is interesting to note that Dr DiFelice uses the standard Reconstruction procedure only as the last resort whereas the majority of #surgeons use it as their only option."

https://www.gregorysdifelicemd.com/olympic-skier-miracle-comeback.html

Analysis of the older data reveals certain subgroups, especially proximal tears with good tissue quality, had better outcomes.   

Again, the acuteness of the tear was a significant factor in repair – it is quite clear the direction I was being in given in Canada was wrong, and reducing the likelihood of a positive outcome.

I email Dr Difelice to find out what I can ask at my appointment this week, and am prepared to go to the US again.

Also email DIS again.  Ensuring I exhaust all potential options.

ACL regrowth BEAR trials (bridge assisted ACL Repair)

After first finding an ACL healed itself, the 2nd thing I found were the BEAR trials run Boston Childrens in these two articles from 2016:

http://www.stack.com/a/radical-new-surgery-allows-you-to-regrow-your-acl 2016 stackmedia

https://www.bostonglobe.com/sports/2016/03/23/new-surgery-could-revolutionize-knee-repairs/BJISuh60AYKYTKWPwaYFWP/story.html Boston Globe

A safety study had been done on 10 patients, all reported “doing well, with knees working as well as knees treated with ACL reconstruction.”  The 1st patient surgery was Feb. 2015 (> 3 yrs ago), for Corey Peak, who also tore it skiing.  He concluded that it was a better option to treat a torn ACL; within 3 months post-surgery, his MRI showed that his ACL had started to naturally knit together; he was jogging on a treadmill. Soon after, cycling to work. 

Bridge Enhanced ACL Repair - How it works:

When viewed under a microscope, ACLs still have active cells and blood vessels after injury.  The ligament itself works hard to heal, however the synovial fluid — the lubricating substance that exists inside of all joints —washes away the blood clot that serves as the initial connection between torn tissue ends in other parts of the body. 

Conventional treatment for an ACL tear involves removing the torn ends of the ligament that’s trying to heal itself, & fabricating another from a tendon graft, usually done by stripping away good tissue (hamstring or patella).  Patients who had 1 injury then have to recover from 2 separate injuries—the torn ligament + the uninjured area where the graft was taken out.

Whereas a traditional reconstructions involves removing good tissue for a graft from another part of the body to fabricate an ACL, BEAR allows patients to re-grow their own ACL. This resulted in both quicker #recovery and fewer long-term complications than the traditional ACL amputation & reconstruction.

An estimated 150,000 ACL tears still occur every year in the USA. “ACL re-tear rate can be as high as 20% for teens.  Up to 80% of patients develop arthritis 15-20 years after surgery.”

Given the eligibility criteria timeline, I need to figure this out fast, as I was at 38 days, and I didn’t want unnecessary ligament removal.

Orthopedics - Intrinsic Healing of the Anterior Cruciate Ligament in an Adolescent

Apr 27-29

The majority of the weekend I spent searching anterior cruciate ligament repairs & learning what an ACL repair is, and the 1st article I found was how a 12 year old boy suffered a complete traumatic rupture of his ACL, which intrinsically healed. 

You can find the article

“Intrinsic Healing of the Anterior Cruciate Ligament in an Adolescent”

in The American Journal of Orthopedics, August 2015

https://mdedge-files-live.s3.us-east-2.amazonaws.com/files/s3fs-public/issues/articles/ajo04408e294.pdf

1 year MRI wait times in Alberta

I receive a call saying MRI appointment is for March 2019

- 1 year away. 

Cannot straighten leg or bend it near 90 degrees.

*Would be 3 weeks post op in US and recovering; being told I have to wait a year now here. 

Consider that other people have families, children or their elders to take care of; or may not be in a financial situation that allows a 1 year pause due to pending injury diagnosis - 1 year is unacceptable for MRI wait times.

It can impact their quality of life, #recovery potential & ability to economically contribute or support dependents. 

This situation supports unnecessary ACL amputation & ACL reconstruction when diagnosis & #treatment is not achieved within the time frame for natural ACL regrowth  - more explanation to follow.

Is MRI magnet time at 100% ?

If so, are we executing Lean Healthcare reducing costs in other areas to free up the available funding to purchase new equipment like so many other hospitals? 

For example, Lean has been used to improve hospital utilization, improving patient outcomes while reducing the need to add entire proposed #hospital WINGS.

When properly applied the CEO frees up $$, space & resources which can be redeployed for additional healthcare services (or MRI suites).

One way to learn a solution Alberta Health Services

- in the same way emergency wait times are consistently reduced through 3-5 day Rapid Improvement events, MRI wait times are reduced the same way.

see how it's done in next post